manual work, reading, and watching television. ... and Medicine (Dr Markert), Wright State University School of Medicine ..... REFERENCES. 1. ... Dorland WA.
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PSYCHOSOCIAL IMPLICATIONS OF BLEPHAROPTOSIS AND DERMATOCHALASIS* BY
John D. Bullock, MD, MS, Ronald E. Warwar, MD, David G. Bienenfeld, MD, Sara L. Marciniszyn, MD, Ronald J. Markert, PhD
AND
ABSTRACT
Purpose: To investigate, for the first time, the psychosocial implications of blepharoptosis and dermatochalasis. Methods: Two hundred ten individuals rated whole-face photographs of a series of patients on the basis of 11 different personal characteristics: intelligence, threat, friendliness, health, trustworthiness, hard work, mental illness, financial success, attractiveness, alcoholism, and happiness. Preoperative and postoperative photographs of both male and female patients with bilateral blepharoptosis and/or dematochalasis were used. The paired t test was used to compare preoperative and postoperative ratings on the 11 characteristics. Results: The preoperative photographs were rated more negatively than the postoperative photographs (P < .01 – P < .001) on all 11 characteristics for both male and female patients by the 210 study subjects. Conclusions: Members of society seem to view individuals with blepharoptosis and dermatochalasis negatively. These psychosocial attitudes may lead to unjust bias toward affected patients, and surgical correction likely provides benefits beyond improved visual function. Tr Am Ophth Soc 2001;99:65-72 INTRODUCTION
The functional visual deficits secondary to blepharoptosis have been well studied. Meyer and associates1 quantified the amount of superior visual field loss observed with various degrees of ptosis by opacifying the superior portion of contact lenses to simulate different upper eyelid positions. Patipa2 demonstrated and quantified the improvement in the superior visual field in primary and reading gaze after surgical correction of ptosis. Health-related quality-of-life issues associated with blepharoptosis have also been investigated. Battu and colleagues3 used a questionnaire pertaining to vision-related activities and symptoms to study the effect of ptosis on patients’ subjective perception of their visual function and quality of life prior to and following surgical correction. They found that postoperative patients perceived a significant improvement in their vision as well as their ability to perform tasks such as fine manual work, reading, and watching television. Using the same questionnaire with 100 different patients, Federici and coworkers4 showed that the severity of the ptosis and the degree of perceived preoperative functional impairment correlated most strongly with the degree of perceived postoperative improvement. In both of these studies, patients reported improvement in self-image postop*From the Departments of Ophthalmology (Dr Bullock, Dr Warwar), Physiology and Biophysics (Dr Bullock), Psychiatry (Dr Bienenfeld), and Medicine (Dr Markert), Wright State University School of Medicine (Dr Marciniszyn), Dayton, Ohio. Funded, in part, by contributions to the Wright State University Foundation, Dayton.
Tr. Am. Ophth. Soc. Vol. 99, 2001
eratively as well.3,4 While these studies have demonstrated the functional visual deficits and the health-related quality-of-life issues associated with blepharoptosis, we are not aware of any previous studies in which the psychosocial implications of blepharoptosis were examined. In the present study, we investigate, through the use of facial photographs and questionnaires, how members of society view individuals with blepharoptosis and dermatochalasis. METHODS
Four sets of 6 different whole-face color photographs were created. In each of the 4 sets, there was a male and female control (a 75-year-old white man and an 81-yearold white woman who did not have clinically significant blepharoptosis or dermatochalasis and who had never undergone eyelid surgery). In addition, there was a preoperative male (a man with clinically significant blepharoptosis and/or dermatochalasis prior to surgical correction), a different postoperative male (a different man who had undergone successful surgical correction of blepharoptosis and/or dermatochalasis), and a preoperative and a different postoperative female. Four different men were used for the preoperative and postoperative male photographs; all were white and ranged in age from 55 to 75 years (mean, 68 years). One of the men underwent a bilateral upper eyelid blepharoplasty, one underwent a bilateral external aponeurotic ptosis repair with levator advancement, one underwent a bilateral upper eyelid blepharoplasty and external
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Bullock et al aponeurotic ptosis repair with levator advancement (Fig 1), and one underwent a bilateral Fasanella-Servat procedure.5 Likewise, 4 different women were used for the preoperative and postoperative female photographs; all were white and ranged in age from 68 to 85 years (mean, 74 years). One of the women underwent a bilateral external aponeurotic ptosis repair with levator advancement, 1 underwent a bilateral upper eyelid blepharoplasty and Fasanella-Servat procedure5 (Fig 2), and 2 underwent bilateral Fasanella-Servat procedures.5 In all patients preoperatively, the eyelids were symmetrical and the margin reflex distance ranged from 0 to 1.0 mm; in all patients postoperatively, the eyelids were symmetrical and the margin reflex distance ranged from 2.5 to 4.0 mm. Each of the 8 surgical patients used in the study had a preoperative photograph in 1 set and a postoperative photograph in another set. All of the surgical procedures were performed by one of the authors (J.D.B). Thus, each study subject viewed photographs of 6 different patients (no study subject viewed the same patient’s preoperative and postoperative photographs).
Study subjects were recruited in suburban shopping malls and received $2 for participating. The subjects were simply informed that they would participate in a study being conducted by Wright State University. The age and sex of each subject were recorded. Each subject was instructed to complete a questionnaire (designed by 3 of the authors [J.D.B., R.E.W., and D.G.B.]) according to their perceptions of each of the individuals in the set of photographs presented. The 6 photographs within each set were shuffled and presented to the subject 1 at a time in random order along with a questionnaire. In each questionnaire, the subjects were asked to rate the individual in the photograph on a scale of 1 to 5 on the following 11 personal characteristics: 1. 2. 3. 4. 5.
intelligence (1 = not intelligent, 5 = very intelligent) threat (1= very threatening, 5 = not threatening) friendliness (1 = not friendly, 5 = very friendly) health (1 = not healthy, 5 = very healthy) trustworthiness (1 = not trustworthy, 5 = very trustworthy)
Some of the photographs from the papers and theses are not available on the Website but can be seen in the published version of the Transactions.
FIGURE 1 Seventy-year-old man with bilateral upper eyelid dermatochalasis and blepharoptosis who underwent bilateral upper eyelid blepharoplasty and external aponeurotic ptosis repair with levator advancement. Left, Preoperative photograph. Right, 3 months after surgery.
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Psychosocial Implications of Blepharoptosis and Dermatochalasis 6.
hard work (1 = not hardworking, 5 = very hardworking) 7. mental illness (1 = very likely to be mentally ill, 5 = not likely to be mentally ill) 8. financial success (1 = not financially successful, 5 = very financially successful) 9. attractiveness (1 = not attractive, 5 = very attractive) 10. alcoholism (1 = very likely to be an alcoholic, 5 = not likely to be an alcoholic) 11. happiness (1 = not happy, 5 = very happy) The scale was designed so that the higher rating represented the more positive aspect of each characteristic. To determine if there was a difference in the way preoperative versus postoperative photographs were judged, the paired t test was used for matched comparisons (ie, the mean rating of all 4 preoperative males versus the mean rating of all 4 postoperative males on each characteristic, the mean rating of all 4 preoperative females versus the mean rating of all 4 postoperative females on each characteristic, and the mean rating of all 8 [male and female]
preoperative patients versus the mean rating of all 8 postoperative patients on each characteristic). For example, the mean rating of the 4 preoperative males for the characteristic “intelligence” was 2.03 (scale: 1= not intelligent, 5 = very intelligent), and the mean rating of the 4 postoperative males for “intelligence” was 2.81. The paired t test was then used to compare the mean ratings (2.03 versus 2.81) to determine if there was a statistically significant difference in the way that the preoperative versus postoperative photographs were judged, and the probability (P) was < .001 that the difference in the ratings (2.81 – 2.03 = 0.78) was due to chance. Such comparisons were made for each of the 11 characteristics for both male and female patients In addition to analysis of the preoperative versus postoperative comparisons of the male and female patients for all subjects, comparisons were broken down for (1) male subjects only, (2) female subjects only, (3) subjects under 21 years of age, (4) subjects 21 to 40 years of age, and (5) subjects over 40 years of age. Significance level (alpha) was set at 0.01.
Some of the photographs from the papers and theses are not available on the Website but can be seen in the published version of the Transactions.
FIGURE 2 Sixty-nine-year-old woman with bilateral upper eyelid dermatochalasis and blepharoptosis who underwent a bilateral upper eyelid blepharoplasty and Fasanella-Servat procedure.5 Left, Preoperative photograph. Right, 4 months after surgery.
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Bullock et al RESULTS
The results are summarized in Tables I and II. The study included 210 subjects, and the data was collected between January and March 1998. The mean age of the subjects was 33.9 years (range, 17 to 76 years); 98 (47%) were male and 112 (53%) were female. For all subjects (n=210) and all patients, the postoperative photographs were rated more positively than the preoperative photographs on all 11 characteristics (P < .001 for all 11) (Table I). For all TABLE I: PREOPERATIVE VERSUS POSTOPERATIVE RATINGS OF PATIENTS WITH BLEPHAROPTOSIS AND/OR DERMATOCHALASIS ON
11 CHARACTERISTIC
Friendliness Alcoholism Happiness Health Mental illness Intelligence Financial success Hard work Attractiveness Threat Trustworthiness
CHARACTERISTICS*
MEAN RATING PREOP
POSTOP
1.85 2.40 1.81 2.06 2.47 2.24 2.13 2.48 1.53 2.89 2.53
2.72 3.26 2.63 2.84 3.21 2.87 2.74 3.06 2.06 3.36 2.94
RATING CHANGE
0.87 0.86 0.82 0.78 0.74 0.63 0.61 0.58 0.53 0.47 0.41
P VALUE†
